Request a Quote

To apply for a workers’ compensation quote with CompSource Oklahoma, please provide the following information,
then click the “Submit” button. An Underwriter will contact you for additional information if needed,
provide you with a premium quote, and mail an application for coverage if desired.

Is this a temporary staffing or employee leasing entity?

yes
no

Do you have operations outside the state of Oklahoma?

yes
no

Total Annual Payroll

Basic Business Information

Business Name

Describe your business operations.

Mailing Address

County

City

State

Zip

Telephone

Format: xxx-xxx-xxxx

Enter with dashes; example: 405-555-5555

Street Address or Directions to Location

Type of Business

Do you have a Federal Tax ID number?

yes
no

Federal Tax ID or SSN

Audit Information

Contact Person: First Name

Contact Person: Middle Name

Contact Person: Last Name

Phone

Format: xxx-xxx-xxxx

Enter with dashes; example: 405-555-5555

Audit Address

County

City

State

Zip

Previous Coverage Information

Have you had previous Workers' Compensation coverage?

yes
no

Carrier Name

Policy Number

Date Cancelled or Expired

MM-DD-YYYY

Anniversary Date

MM-DD-YYYY

State

Experience Modifier

Modification Effective Date

MM-DD-YYYY

Rating ID Number

Carrier Information for the Last 3 Years

Carrier Name 1

Policy Number 1

Policy Period 1

Carrier Name 2

Policy Number 2

Policy Period 2

Carrier Name 3

Policy Number 3

Policy Period 3

CompSource Workers' Compensation Supplemental

Do you own any other business entities in Oklahoma or in any other state(s)?

yes
no

Do you need workers’ compensation and employers’ liability insurance coverage in those states in which you have operations?

yes
no

Do you intend to obtain a quote for all Oklahoma business entities?

yes
no

Explain

Do you have employees permanently working in Oklahoma whose contract of hire is outside the state of Oklahoma or who resides in a state outside of Oklahoma?

yes
no

List the contract of hire or state of residency for each employee.

Do any of your business entities have permanent operations or locations outside of Oklahoma?

yes
no

List the state(s).

Are you currently in the process of liquidation or termination of this business?

yes
no

Please explain.

Are you related to or associated with anyone in this business who has been denied coverage, cancelled, non-renewed or billed premium on a cancelled policy that remains unpaid with CompSource Mutual or CompSource Oklahoma?

yes
no

Please name.

Do you currently employ or intend to employ any domestic employees?

yes
no

Do you currently employ or intend to employ any farm employees?

yes
no

Do you now or in the future hire family members related by blood or marriage?

yes
no

Business is domiciled/headquartered outside Oklahoma?

yes
no

Do you have employees who permanently work or reside in Oklahoma who may travel or work outside the state of Oklahoma?